MOH Budget Speech (Part 2) - Transforming Healthcare

06 Mar 2007

By Mr Khaw Boon Wan, Minister for Health

Venue: Parliament

Just now, we discussed how we must gear up Singapore for our healthcare needs of 2020.  We discussed the 3 key resources that we will need: financial, physical and human resources.  But having more resources alone will not necessarily lead to a better healthcare system.  Witness the huge amount of resources some countries are pouring into their healthcare today and yet they deliver much poorer outcomes than other countries which spend much less.   More of the same will not do.  We need to have the courage and wisdom to transform healthcare.

Transforming Healthcare

2. Some analysts in the automobile industry compared GM with Toyota and criticised GM for being too product-focused.  They praised Toyota for focusing on the changing needs of customers over their lifetime.  Parents buy a small car for their child when he graduates from high school.  A young adult buys a Corolla, then an MPV when his family grows, and when he gets promoted, he buys a Camry, later a Crown and so on.  Toyota made over a hundred models to meet the needs of different market segments.  

3. Healthcare is unfortunately more like GM than Toyota.  We focus on buildings, equipment and skills.  This is not wrong but we are not paying enough attention on the varied needs of our patients. Let me give some examples:

• An infant with a hole in the heart needs a one-off highly specialised care involving a large team of specialists and other staff to fix the problem using highly sophisticated equipment.  But once fixed, the infant will be more or less normal and well.

• Another infant born with severe brain damage will also require sophisticated care but the best outcome may still be a lifetime of pain, discomfort and total dependency.

• An 80-year old with advanced cancer may also need highly specialised care involving experts and sophisticated equipment.  But the outcome may be a prolongation of life for a few weeks with pain and discomfort.

• Another patient in a similar condition may well choose a less aggressive treatment regime focusing mainly on palliative care.

• A young person with a broken bone needs a surgery and after a few weeks will be back to normal.  The surgeon plays a key role and the patient plays only a relatively small role in that treatment episode.

• On the other hand, an obese patient with diabetes will need life-long medical attention.  The patient's well-being is almost entirely dependent on his personal willingness to change his lifestyle and follow the treatment regime strictly.  The healthcare team can only play a supportive role.

4. As you can see, a patient's treatment choice is often determined by a complex interplay of his understanding of likely outcomes, advice from his doctors and friends, his personal expectations, values and philosophy, and his ability and willingness to pay for treatment.  Clearly, one size cannot fit all.  Even a dozen sizes will still not fit many.  There is a need for us in healthcare to segment patients more, clearly understand their needs by observing them closely and consulting them.  We have to develop practical treatment strategies, innovate and continuously fine-tune approaches to improve outcome and reduce cost.

5. To transform healthcare to better meet the different needs of our patients, we must innovate.  To innovate to meet diverse needs, we must have diversity in organisations, structures, models of care and pricing.  This requires a change in mindset on the part of the healthcare providers.  For example, hospital specialists will need to work more closely with Family Physicians and step-down care facilities as a team, with patients at the centre.  Ideally, they will all share a common medical record for each patient, consult regularly and function as a team whose sole purpose is to advance the health of the patient.

6. This is challenging even when all the healthcare providers are from one single employer and serve patients with the best of intentions.  Complications multiply many-fold as such a team often comprises members coming from all the 3 sectors: public, private and charity sectors.  Co-ordination and trust take time to build.  That is why true care integration has not yet happened, whether here in Singapore or in other countries.  It will take years, not months, to achieve such an optimal outcome.  Many pieces have to fall in place.  Let me highlight some.

Electronic Medical Record

7. First: an important infrastructure is the Electronic Medical Record (EMR).  I have coined the slogan, "One Singaporean, One EMR" to catalyse this initiative.  Right now, it is one Singaporean, multiple medical records, stored away in different clinics and hospitals in different formats, and not connected or consolidated.  As a result, when patients visit different doctors, they have to have tests repeated and scans redone.  This adds to unnecessary cost.

8. We are moving towards this target of "One Singaporean, One EMR".  Because of legacy systems, we cannot achieve it in one step.  But we have made progress.  As pointed out by Dr Lam Pin Min, public hospitals now have the EMR eXchange (EMRX).  We achieved a first but important psychological step in 2004 when public hospitals began to electronically exchange their Hospital Inpatient Discharge Summaries. Since then, we have made the EMRX more comprehensive, by adding other patient records such as laboratory tests, radiology reports and medication information.  The electronic volume of laboratory results exchanged has grown 7 times in 2 years.  Thousands of patients benefit from EMRX every month.

9. Our doctors' feedback is that EMRX has made their work easier. In particular, our Emergency Department doctors have said that the EMRX gives them greater reliability and confidence in treating patients, especially those with long and complicated medical histories.  Extending EMRX to private doctors will be a natural step and is the objective.  As Dr Lam pointed out, a National EMRX will minimise unnecessary medical investigations. More importantly, I see EMRX playing a critical role in the integrated delivery of care to patients.

10. However, this is a complex national project - very few if any countries have successfully implemented a system that links up public, private and the charity sector.  This is because there are many issues such as data protection, regulation and audit to be addressed.  We need to take a measured approach, to pilot and put together a comprehensive framework that takes care of these issues.  This will begin with common data standards.  We will do this within the public sector, and extend this to the step-down institutions.  We have started to build the linkages to the private sector GP clinics by helping them to set up their IT systems under the Chronic Disease management effort.  I am confident that we will get there.

Care Integration

11. Second: we need to strengthen the collaboration between acute hospitals and community hospitals to achieve seamless care for patients when they move between these two types of institutions.  For patients who no longer need medical treatment in acute hospitals and who should move into community-based care, we must ensure the continuity of patient care and eliminate barriers and bureaucracy. The handover must be smooth, as though it is from one ward to another within the same hospital.  For a start, we need to enhance medical collaboration between the doctors in our acute hospitals and either their counterparts in the community hospitals or the Family Physicians who look after the patients over the long term.  Patients must feel confident that they are getting seamless care.

12. The same approach is needed for patients who require care at nursing homes.  We are working with MCYS on this.  We are also studying the longer-term feasibility of integrating different residential and community-based healthcare and eldercare facilities, so as to help the elderly to age-in-place and continue using familiar facilities even as their care needs change with time.

Right-Siting

13. Third: we need to have patients treated in the most appropriate locations by medically-competent teams at the lowest possible cost.  This is referred to as "right-siting" healthcare services.  The logic is obvious.  But the outcome is seldom the case.  Today, many patients who choose to be treated at SGH and NUH need not be there and should not be there.  They can be and should have been treated by their Family Physicians, at less hassle and at lower cost.  But for various reasons, they get wrongly-sited there.  Wrong pricing, as observed by Mdm Halimah, is one factor.  Mdm Halimah's proposal is for us to reduce prices at step-down care so that patients will have an incentive to leave the hospital.  To achieve this, Mdm Halimah suggested that we exempt patients to be transferred from hospitals from means-testing at nursing homes.  I am afraid I do not agree.  The correct solution is to extend means-testing at nursing homes to the hospitals so that we eliminate this policy anomaly.  I have asked MOH to study how we can do so, at least for those patients who have exceeded the average length of hospital stay.

14. Meanwhile, we will continue our push, through the Medisave for chronic disease scheme, to shift chronic disease management to the primary care level, by Family Physicians and in the community.  If patients can be right-sited to Family Physicians and feel confident that they will be well looked after, we can reduce the over-crowding at the hospital specialist outpatient clinics.

Exploiting Technology

15. Fourth: we must exploit technology to improve care and lower cost. Telemedicine is a good example and can potentially bring benefits to many areas of healthcare.  We have started with tele-radiology in our polyclinics with very good results.  Patients save time as they no longer need to make a return trip for their results. Increased competition has resulted in cheaper X-rays and improved turnaround times from local radiologists.  Almost 60,000 patients benefit from this per year.

16. We are moving beyond simple X-rays to CT scans and MRIs.  I have no doubt this will bring further benefits, and those cost savings will be even more significant.  We will continue to study other applications of telemedicine and get it to work for our patients here.  I have also encouraged our radiologists, where there is spare capacity, to sell their services to buyers in developed countries.  We can sell tele-radiology services, as well as buy it.

Clinical Research

17. Fifth: medical science here will continue to progress, and we have reached a stage where Singapore should be part of the global search for faster diagnoses, better and more cost-sustainable care for patients.  Our public sector doctors have always been bogged down with heavy patient loads.  If we are able to recruit more doctors to improve our doctor-patient ratio, we can ease their burden somewhat.

18. Through this process, we hope some doctors with special interest in clinical research will find more opportunities to do so.  Every generation of doctors has always yielded a few outstanding researchers, for example Professors Wong Hock Boon, SS Ratnam and more recently, Ng Soon Chye, Yap Hui Kim and Donald Tan.

19. With our latest emphasis on life sciences development, public hospitals will now be better supported with research funds to pursue this interest.  Over the next 5 years, MOH, National Research Foundation and A*STAR will jointly contribute $1.55 billion to support translational and clinical research.  It is a major boost to our researchers, although in the scheme of things it is not a huge pool of funds.  So we will have to prioritise and focus on specific areas where Singapore-based researchers already are strong or in diseases where strong capabilities can best benefit Singaporeans.   Because the greatest potential impact will come from areas where we are strong along the value chain from basic sciences to clinical treatments, we will encourage our doctors in the hospitals and the scientists in the laboratories to work very closely together.

20. We will not be able to allocate research funds equally to each hospital.  Hospitals and researchers will have to compete for them.  Those who are able to better manage unnecessary overcrowding and free up manpower resources will have an advantage.  That is why it is so important for hospital specialists to learn to work with the GPs, to co-manage the chronic patients and make right-siting of care a reality.

Organisational Changes

21. Sixth: we should not shy away from organisational changes that can help us achieve our mission more effectively.  That is why we restructured hospitals more than 20 years ago.  We moved from central planning by MOH HQ, almost communist-style, to a decentralised competitive model allowing individual hospitals greater room to innovate.  How else can we nurture experimentation and bring out improvements?

22. Mr Sam Tan asked if our restructured hospitals are wasting resources on rich patients and foreign patients, at the expense of subsidised patients.  All patients, poor or rich, receive competent clinical care.  Thus all patients requiring urgent medical attention are promptly seen: 3 minutes for the critically-ill; 30 minutes for other true emergency cases.  For non-emergency cases, service standards vary and we publish such data so that patients can choose the less busy hospitals. All doctors who practice in the public sector will treat subsidized patients.  This is part of the ethos of public service which our doctors feel strongly about.

23. As for physical provisions, the Ministry decides on the distribution of beds among classes.  The fact is that 80% of beds in Singapore are in public hospitals and over 70% of public hospital beds are heavily-subsidised B2 or C beds.  In other words, more than half of the patients treated in Singapore are subsidised by the Government, to more than 65% of the cost.  We also have guidelines in place to ensure that public hospitals do not spend on lavish fittings and renovations. But some renovation is inevitable to enhance efficiency and to meet public expectations. Nobody wants to be admitted to a run-down hospital.

24. Mr Low Thia Khiang asked if our hospital cluster system has led to wasteful duplication and if integration has led to better service level.  One key objective of clustering is in fact to facilitate better integration of care between hospitals and polyclinics.  This remains an important objective as I have outlined earlier.  We have made some progress integrating public hospitals and polyclinics, but full integration requires us to bring in the private GPs and the rest of step-down care providers.  So our journey to restructure and bring about organisational change continues.  Certainly, our hospital clusters will make a big push on this front this year, but it will always be work-in-progress.  We must never be fossilised into a concrete structure and become unresponsive to external changes and expectations. Mr Low made an additional point for certain specialities to be centralised. My view is that both centralisation and de-centralisation are viable, but the solution would depend on the nature of the particular speciality. Both methods have their advantages and disadvantages.

25. At the end of the day, organisational structures are the means to an end.  Our mission is to serve patients, particularly those in the lower half of the population.  When a person falls sick, what does he want out of our healthcare system?  Two simple questions: what is wrong with me? And what can you do to help me recover?

26. Our job is to provide answers to these questions and do so in a way which makes the total care experience for patients as smooth as possible and does not bankrupt him or our society.  But as I stressed just now, patients too have a big part to play. 

27. Mr Sam Tan spoke about Health Maintenance Organisations (HMOs) which organised the GPs and then market their services to some company employees.  It is an idea imported from the US.  I do not how wide is their coverage but while we do not regulate HMOs, we do regulate the doctors working for them.  I am sure any attempt by HMOs to cut corners will be resisted by our GPs as they have high ethical standards.  Companies should also chip in to ensure that their employees do not get short-changed.

Market Transparency

28. Seventh: we will release even more information to Singaporeans.  We will measure and publish outcomes and performance indicators, to increase market transparency and help patients make better choices.  NUH, KKH and SGH have recently, through their own initiative, begun to publish clinical outcome data on their respective websites.  This is a first for any hospital in Singapore, and I applaud their public commitment to quality improvement and greater transparency.  I will encourage all our hospitals, both public and private, to publish outcomes and benchmark themselves with international outcomes.

29. This will similarly apply to step-down care providers.  My Ministry is working with them to develop indicators to measure their performance in service development, utilisation and clinical quality.  We will ensure that minimum care standards and patient safety are met.  For those who do not perform well, we will help them improve their standards.

Empowering Patients

30. Eighth: we need to further empower our patients by engaging them in their care and their care choices.  Patient empowerment led me to introduce the Medisave scheme for chronic diseases last year.  We know that chronic diseases account for the bulk of the workload in public hospitals and the polyclinics.  These diseases will not go away and, if left unmanaged, will only get worse, not suddenly but gradually over time.

31. Fortunately, medical science is now clearer on how to manage these chronic diseases to minimise future complications.  The correct approach comprises 3 elements: (a) early detection; (b) regular ongoing low-tech low-intensity treatment by Family Physicians; and (c) good compliance by patients in changing their lifestyle and habits.  The wrong approach is to ignore these diseases, persist with an unhealthy lifestyle, then when complications emerge, rush into hospitals for high-tech, high-intensity attention by multiple specialists, hoping for a cure and a quick return to the same lifestyle.  But there is no such cure.  It is wishful thinking.  When a chronic illness is still mild, that is the time to change your lifestyle and begin treatment.  If you wait, the complications are a lot harder and much more costly to manage.

32. With the Medisave scheme for chronic disease management, I hope to bring about a mindset change among our chronically ill.  Through Medisave, we have eased the financial burden.  It is now up to the patients to come forward and help themselves, to work with their doctors to actively manage their chronic diseases.  If they do so, their health will improve.  It can be done.  In small-scale pilots, we have seen such improvements among participating patients.  Through Medisave, we are scaling this across the nation. Mr Low Thia Kiang asked about the cost of treatment at the polyclinics. With early treatment for their conditions, patient will incur lower costs in the long run. The actual cost of their treatment is also dependent on their conditions. With this structured programme, we hope to encourage patients to avoid doctor hopping and for each Singaporean to have one Family Physician.

33. Now that we have got over the implementation phase, we will use this whole year to collect and analyse the outcomes.  By next year, we should be better able to answer some questions as posed by Mdm Halimah and others: how do the various clinics perform in terms of managing their patients' chronic diseases?  How much do they charge their patients and for what treatments?  Are their patients showing signs of improvement? I will be publishing these outcomes so that patients can make better choices on which family physician to visit.

34. Every patient should be given a personal health information folder by his doctor on his chronic disease and what he should do to improve his health.  His health status should be regularly tracked and charted, and explained to him by his doctor.  If your doctor does not do this for you, ask him why not.  Suitably empowered, I hope many patients will take their health more seriously and work to improve on it.  If we do it well, the long-term impact will be significant.  If it cuts down unnecessary hospital care, it means major savings in dollars and human suffering.  Let us work to make it succeed.

SingaporeMedicine

35. Finally, let me touch on SingaporeMedicine, the strategy to attract foreign patients to Singapore.  This is an economic objective, not a strictly healthcare mission.  My advice to the public hospitals is that SingaporeMedicine is not our primary objective but a secondary and consequential outcome.  Our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices.  That is our mission.  But if our standard is high and our prices are reasonable, Singapore is bound to attract many foreign patients, as we always do.

36. Our regional neighbours have raised their medical standards over the years.  But we remain ahead of them, and should always strive to stay ahead.  If we do our job well in serving Singaporean patients, we will always attract foreign patients.  It is a validation of the quality of our healthcare.  We should therefore factor in this reality when we make projections of hospital beds, doctors, nurses and so on.  If we do not do so, and since we cannot prevent foreigners from coming here for treatment, public hospitals and subsidised patients will get crowded out.  If nothing else, costs will go up because private hospitals poach public sector doctors and nurses, pushing up wages.  This is the reason why we are stepping up foreign recruitment of foreign doctors and nurses, even as we ramp up local training.

37. While we may see some visiting foreign patients in public hospitals, the fact is that the majority of foreign patients go to the private hospitals and clinics.  80% of foreign inpatients stay in the private hospitals.  Foreign patients make up less than 2% of public hospital admissions.  Ultimately, I agree fully with Mdm Halimah that SingaporeMedicine must benefit Singaporeans, and must not come at the expense of care for Singaporeans.

38. Mr Chairman, I believe I have addressed all the queries by Members.  I know Mr Low Thia Khiang spoke on HOTA.  He was not in this House when we had a full discussion on the SGH incident brought up by Dr Lim Wee Kiak.  In the interest of time, I do not wish to repeat the points already made here last week, except to say that we will learn from the SGH incident and try to do a better job.  We will certainly step up public education on organ donation and brain death and help Singaporeans think about the plight of those fellow Singaporeans on the waiting list.  As I said in this House, it is often the luck of the draw.  We can never be sure whether we may end up on the waiting list.  Before HOTA, we could only save 5 lives a year.  After HOTA, we now save a life a week.  This is the reality of HOTA.  HOTA is good both for the dead and the living.  But we respect the wishes of those who want to opt out of HOTA.  We will facilitate it.  Every year, about 2,500 opt out of HOTA.  The number went up soon after the SGH incident but has since come down to 80 a day.  I respect the wishes of those who opted out but I worry for the poor patients on the organ waiting list.

From Good to Great

39. In conclusion, I acknowledge that our healthcare system is not perfect.  But it is actually not bad.  My foreign counterparts told me so.  They would happily trade off their systems for ours.

40. But it can be better.  Over the next few years, we will get the pieces together and be better ready for the challenges ahead.  I thank Members for their continuing support and advice.